| NPI | 1316400609 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: CA 20A19375) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA 20A19375) |
| Enumeration Date | 2019-04-12 |
| Last Update Date | 2026-07-03 |